Healthcare Provider Details

I. General information

NPI: 1619252533
Provider Name (Legal Business Name): GARY BERNARDI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 11/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 YORK ST
NEW HAVEN CT
06510-3220
US

IV. Provider business mailing address

130 LAKE ST
WEST HAVEN CT
06516-6816
US

V. Phone/Fax

Practice location:
  • Phone: 203-688-2615
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number004837
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: